Patient Profile: Patient is a 35 year old, single, Caucasian male, truck driver.
Chief Complaint: Patient is concerned with the appearance of his mouth.
Dental History: Patient bleeds when brushing his teeth and has recurrent sores in his mouth that he states are painful. He recieves regular teeth cleanings one time a year. Last DDS Exam was on October 20, 2009. Last radiographs were bitewings also on October 20, 2009.
Medical History: Patient had Pneumonia two months ago and it was treated with antibiotics. He has a visual impairment that is corrected with glasses. Patient is HIV positive and indicates that his CD4 count is 350 cells/mm3 and his platelet count is 40,000 per microliter. Patient vitals are within normal limits.
Patient Medication: Lamivudine, Abacavir, Zidovudine, and a multivitamin.
Medication: Abacavir Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002 Dosage: 300 mg Twice a Day Taken For: Treatment of HIV infection Dental Implications: N/A Dental Contraindications: N/A
Medication: LamiVUDine Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002 Dosage: 150 mg Twice a Day Taken For: Treatment of HIV infection Dental Implications: N/A Dental Contraindications: N/A
Medication: Zidovudine Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002 Dosage: 300 mg Twice a Day Taken For: Treatment of HIV infection Dental Implications: taste perversion, oral mucosa pigmentation, dysphagia, and mouth ulcer. Dental Contraindications: N/A
Medication: Centrum Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2000 Dosage: 1 Tablet Taken For: Multivitamin Dental Implications: N/A Dental Contraindications: N/A
Medical consult: The patient was sent to his physician to verify that he can be safely treated for a cleaning
Clinical Findings: The following assessments were gathered at his first appointment Extra oral: within normal limits. Intra oral: patient has a 3mm by 3mm aphthous ulcer on his left buccal mucosa opposite of tooth # 14. Gingival description: The free gingiva is generalized erythmatous, spongy, scalloped, and shinny, with localized hemorrhagic, flaccid, purulent, and cratering, and sloughing in the LRQ. The attached gingiva is generalized erythmatous, fibrotic, and hyperkeratosis. MBI: 15% Probing depths: generalized 3-5mm BOP: 34% Recession: 2mm on buccal of #27-28, 30 & 32, 3mm on buccal of #29 & 31. Muccogingival defects: none Mobility: + 23-26, Class II on #30 Fremitits: + 7-10 Furcations: Class III on the buccal of #30. Angles class: Class I bilaterally Facial profile: Mesognathic Salivary flow: adequate ASA: Class III ADA: Generalized III AAP: Generalized moderate with localized severe chronic periodontitis due to plaque and calculus and modified by HIV. Calculus code: Full mouth Medium
Referral form
The following was noted during the DDS Exam and explained to the patient:
Critical Thinking Form Do to the assessments that were collected the patient needs the following treatment.
Treatment Plan
The following is the treatment plan for Mr. Case #3, assuming he brought in an FMX. Chlorehexidine will be administered to all pocket depths 5mm and over. For comfort of the patient and operator, anesthesia will be used (2% Lidocaine with epinephrine 1:100,000).
Prognosis
Based off the assessments gathered, with adherence to oral hygiene instruction and maintaining recare appointments Mr. Case #3 will see slight improvements in his oral appearance. His generalized prognosis is fair and localized poor prognosis for #30 due to the class III furcation.
Periodontal Case #3 - HIV
Patient Profile: Patient is a 35 year old, single, Caucasian male, truck driver.
Chief Complaint: Patient is concerned with the appearance of his mouth.
Dental History: Patient bleeds when brushing his teeth and has recurrent sores in his mouth that he states are painful. He recieves regular teeth cleanings one time a year. Last DDS Exam was on October 20, 2009. Last radiographs were bitewings also on October 20, 2009.
Medical History: Patient had Pneumonia two months ago and it was treated with antibiotics. He has a visual impairment that is corrected with glasses. Patient is HIV positive and indicates that his CD4 count is 350 cells/mm3 and his platelet count is 40,000 per microliter. Patient vitals are within normal limits.
Patient Medication: Lamivudine, Abacavir, Zidovudine, and a multivitamin.
Medication: Abacavir
Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002
Dosage: 300 mg Twice a Day Taken For: Treatment of HIV infection
Dental Implications: N/A
Dental Contraindications: N/A
Medication: LamiVUDine
Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002
Dosage: 150 mg Twice a Day Taken For: Treatment of HIV infection
Dental Implications: N/A
Dental Contraindications: N/A
Medication: Zidovudine
Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2002
Dosage: 300 mg Twice a Day Taken For: Treatment of HIV infection
Dental Implications: taste perversion, oral mucosa pigmentation, dysphagia, and mouth ulcer.
Dental Contraindications: N/A
Medication: Centrum
Last Time Taken: 8:00am This Morning Period of Time Taken: Since 2000
Dosage: 1 Tablet Taken For: Multivitamin
Dental Implications: N/A
Dental Contraindications: N/A
Medical consult:
The patient was sent to his physician to verify that he can be safely treated for a cleaning
Clinical Findings:
The following assessments were gathered at his first appointment
Extra oral: within normal limits.
Intra oral: patient has a 3mm by 3mm aphthous ulcer on his left buccal mucosa opposite of tooth # 14.
Gingival description: The free gingiva is generalized erythmatous, spongy, scalloped, and shinny, with localized hemorrhagic, flaccid, purulent, and cratering, and sloughing in the LRQ. The attached gingiva is generalized erythmatous, fibrotic, and hyperkeratosis.
MBI: 15%
Probing depths: generalized 3-5mm
BOP: 34%
Recession: 2mm on buccal of #27-28, 30 & 32, 3mm on buccal of #29 & 31.
Muccogingival defects: none
Mobility: + 23-26, Class II on #30
Fremitits: + 7-10
Furcations: Class III on the buccal of #30.
Angles class: Class I bilaterally
Facial profile: Mesognathic
Salivary flow: adequate
ASA: Class III
ADA: Generalized III
AAP: Generalized moderate with localized severe chronic periodontitis due to plaque and calculus and modified by HIV.
Calculus code: Full mouth Medium
Referral form
The following was noted during the DDS Exam and explained to the patient:
Critical Thinking Form
Do to the assessments that were collected the patient needs the following treatment.
Treatment Plan
The following is the treatment plan for Mr. Case #3, assuming he brought in an FMX. Chlorehexidine will be administered to all pocket depths 5mm and over. For comfort of the patient and operator, anesthesia will be used (2% Lidocaine with epinephrine 1:100,000).
Prognosis
Based off the assessments gathered, with adherence to oral hygiene instruction and maintaining recare appointments Mr. Case #3 will see slight improvements in his oral appearance. His generalized prognosis is fair and localized poor prognosis for #30 due to the class III furcation.